practice nurses programme gpcme rotorua 2010 peter... · practice nurses programme gpcme rotorua...
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Practice Nurses ProgrammePractice Nurses ProgrammeGPCME Rotorua 2010GPCME Rotorua 2010
Peter ChapmanPeter Chapman--SmithSmithSkin and Vein Clinic Skin and Vein Clinic
Whangarei Whangarei –– Otago Otago -- Hibiscus CoastHibiscus Coast
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1-2% public health cost annually in NZ80% are venous in origin20% arterial, diabetic, decubitus, malignant etc…
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40-70% of the populationMen and womenSedentary occupationsFH Hormonal- grand multipsUrban > rural
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Nursing – debridement, dressings, sepsis Compression – class 2 hose, layered bandaging Rx of underlying cause = varicose veins – CVI,
chronic venous hypertension, interstitial oedema, local ischaemia and hypoxia
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Ulcer pre EVLA
12 months
Prior ulcer scar
3 months
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6mths post 6mths post 12 mths 12 mths Pre Pre
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Bimalleolar Ulcers x10yrs. 18cm diameterBimalleolar Ulcers x10yrs. 18cm diameter
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EVLA EVLA –– hairdresser 43yrs hairdresser 43yrs
3 mths
6 mths
12 mths
Pre Rx
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Graduated Compression Higher pressure at ankle Promote cephalad flow of blood
Reducing ambulatory venous pressure: Compress varicose veins Prevent pooling at ankle Reduce oedema
PVD can be a problem – ABIs Tubigrip second best
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Compression power, height on legCompression power, height on leg Level of compression at the ankle European Standard
1 – 18-21 mmHg 2 2 –– 2525--32 mmHg32 mmHg 3 – 36-48 mmHg 4 – 48+ mmHg Travel – 8-15mmHg
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18 mmHg Use: prevention of DVT intra and post-operatively
Manufacturers Recommendation:““For use in the nonFor use in the non--ambulant convalescing patientambulant convalescing patient””
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NOT designed for ambulant use
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Duoderm, Comfeel, Allevyn ……… Honey Silver, seaweed (arginates) Ichthyopaste
THEY ALL WORKTHEY ALL WORK
Frequency 1-2 x weekly XXX saline and guaze
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
After foam UGS
Varicose VeinsVaricose Veins
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Retrograde downward flow
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Varicose eczema Thrombophlebitis Pigmentation Bleeding Ulceration DVT risk Reduced QOL
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Lipodermatosclerosis
= skin infarction
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Lower venous pressure (top)
Higher hydrostatic pressure lower leg
Bluish feet, poor oxygenation and skin nutrition
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast 25% incidence VVs25% incidence VVs
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
? Normal? Normallegslegs
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Reflux
Augmentation
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Normal scan, Blood flow to the heart
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Severe varicose veins.Severe varicose veins.
Blood retrograde flow Blood retrograde flow
Duplex US MapDuplex US Map
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Surgical - Non surgical – EVLA, RF, UGS
Issues: efficacy, safety (VTE risk ), scarring, recurrence , QOL, patient compliance and cosmesis
Risk v gain Chronic relapsing disease Often not diagnosed
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None – ignore them External Lasers Creams…..”Vein Away” Graduated compression hose Surgery- ambulatory phlebectomy, stripping , flush
ligation, stab avulsion, endoscopy, morcillation. Free injection (blind) UGS- US Guided Sclerotherapy VNUS EVLA ELLE catheter Combined UGS & EVLA
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
1.Recurrence after varicose vein surgery: A prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. Andre` M. van Rij, MD, FRACS, Perry Jiang, MB, ChB, Clive Solomon, FRACS, Ross A. Christie, NZCS, and Gerry B. Hill. (J Vasc Surg 2003;38:935-43.)2. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomised controlled trial of stripping the long saphenous vein. J Vasc Surg 2004;40: 634-9.
Surgery for VVs Surgery for VVs •Time off work 1-3 weeks•Scars•GA risks•VTE risk 5%Recurrence post Surgery:Recurrence post Surgery:•SFJ : 23% at 3 yrs•SPJ : 52% at 3 Yrs•Clinical recurrence 47.1% at 5 yrs, 62% at 11yrs•Physiologic recurrence 66% at 5 yrs
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Endovenous Laser Ablation (EVLA)
Ultrasound Guided Sclerotherapy (UGS)
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
•97.5% closure at 1 yr (810nm diode)•93.5% closure at 2 yrs, 3yrs•Recurrences mostly in the first 3-9mths
•5yr data 1320nm Whangarei – 0.001% re Rx rate
Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term Results Robert J. Min, MD, Neil Khilnani, MD and Steven E. Zimmet, MD . 2003
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Injecting a foreign substance into a vessel lumen causing endothelial damage , with or without thrombosis,
inducing total FIBROSIS of the vessel.
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Popular Cheaper – procedure, time off Safer- low VTE risk (1:1500); no GAs, nerve damage, scarsImmediately ambulant – RTW stat1st choice Rx most Western countries
Combined EVLA and UGS best Combined EVLA and UGS best
Easily repeatable
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
SSV
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Vein symptoms are Vein symptoms are not related to vein sizenot related to vein size
Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Before UGS After
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Before1 previous surgery
6 months after UGS,and microsclerotherapy
Scars
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Pre UGS 30 days 2 yrs
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
Two years post UGS
Great Saphenous vein
Transverse view
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Skin & Vein Clinic, Whangarei.Otago.Hibiscus Coast
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Deep Vein ThrombosisDeep Vein Thrombosisandand
Pulmonary EmbolismPulmonary Embolism
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1-2 per 1000 per year 2/3 are DVT 1/3 PE Risk doubles every decade after age 40
Major complications Post thrombotic syndrome (PTS) Death (PE) Bleeding (Warfarin)
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Swelling Pain, tenderness Pitting oedema Distension of superficial vessels Positive Homan’s sign Shortness of breath Cutaneous erythema
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Surgery 20% Trauma 12% PHx - DVT / PE 25% Immobility (Hospital or Nursing Home) 8% Lower Extremity paresis 3% Cancer 4-6% Hormone replacement therapy 2% Oral Contraceptive pill 3% Inherited Thrombophilia
Factor V Leiden (>50%) Protein C, S deficiency Lupus
Risk FactorsRisk Factors
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Pregnancy Heart Disease Obesity Sepsis Age Gender (Female > Male)
Sedentary occupation
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2 million cases DVT in USA pa PE 300,000 deaths pa in USA PE : leading cause of hospital preventable death 50% chance of PE with proximal DVT ( ? sx) 3-5% chance of PE with distal DVT DVT risk factors- PH DVT, FHx thrombophilia L term risk post thrombotic syndrome
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• Blood Vessel Wall (endothelium)
• Blood Flow – smooth, turbulent, slow etc
• Blood factors as “Hypercoagulability”
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Recent hx: trauma, or surgery• Thrombocytosis• Activated platelets• Elevated procoagulant proteins – F VIII, fibrinogen
(consider tissue factor)• Reduced anticoagulant proteins – AT3,
plasminogen activator inhibitor.• Blood flow – venous stasis, local hypercoagulability
Generalised hypercoagulability Generalised hypercoagulability (“thrombophilia”) –congenitalinheritedacquired
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Predisposition to venous thrombosis (rarely arterial)
ClinicallyClinically: unprovokedunprovoked DVT,PE +/- FHxLaboratoryLaboratory: deficiency anticoagulant factors
(usually hereditary) or added procoagulant factors (usually transient
and acquired)
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• Antithrombin III - High• Protein C - Moderate to High • Protein S - Low • Activated Prot C Resistance (FV Leiden) Low
• Factor V Leiden - Low RR 8
• Prothrombin Mutation (PTG20210A) Low RR 4-8• Homocysteine – high relevant ? Causal- acquired/congenital• Lupus Anticoagulant (APLS) – ? acquired , high risk• Anticardiolipin Antibodies – IgG and IgM • Others – platelets, fibrinogen, FVIII etc
30% with strong FH - no diagnosis
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• History – provoked or unprovoked• Personal risk factors• Clinical evidence• Personal risk questionnaire• Family history• D-Dimer (useful if NEG)• Wells Score• Imaging – duplex US, venography, pulmonary CTA
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Compressed vein
V
AA
A
V Non-compressible vein
A
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Score
Active cancer 1
Paralysis or recent plaster immobilisation 1
Recent immobilisation for more than 3 days or major surgery
within 12 weeks requiring general or regional anaesthesia.1
Localised tenderness along the deep venous system 1
Entire leg swollen 1
Calf swelling (circumference >3cm more than normal side
measured 10cm below tibial tuberosity)1
Pitting oedema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Alternative diagnosis as likely or greater than that of DVT -2
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Well’s Score
Duplex ultrasound scanDuplex ultrasound scan
Score ≥2High Probability
D-dimer on way to scan
Score <2Low Probability
D-dimer <200 D-dimer >200
No scan necessary
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Byproduct of Fibrinolysis Diagnoses thrombotic activity Non-specific in diagnosis of DVT
-ve D-dimer = DVT unlikely +ve D-dimer = DVT or other coagulable state
Other conditions cause raised D-dimer Active cancer Pregnancy Infection Post-surgery Inflammatory processes Trauma
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Large differential diagnosis Ruptured Baker’s cyst Cellulitis Haematoma Compartment syndrome Superficial thrombophlebitis Lymphoedema CHF Adenopathy
Need standardised procedure…
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• LMWH (Clexane) • Start Warfarin same time• Aim INR of 2-3 in 48hrs• Optimum therapeutic effect 4-5 days, then stop
LMWH • Continue Warfarin for 3 – 6 months• Monitor INR – not >3 usual• Consider risk of re thrombosis
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Reported in 15Reported in 15--50% of patients with DVT50% of patients with DVT Severe PTS 5% at 10 year follow upSevere PTS 5% at 10 year follow up Higher thrombotic load (proximal DVT) higher risk PTS increases the risk of further VTE.
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Pain Oedema Hyperpigmentation (7-23%) Ulceration (4-6%) Lipodermatosclerosis (champagne glass leg) Heaviness Cramps Itchiness Numbness or tingling Dilatation of superficial veins Redness
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Chronic mechanical problem- CVI , damaged valves. Reduced blood flow, swelling, and limb pain. Leg pain and swelling Leg pain and swelling = post thrombotic syndrome.
Valve leaflets damaged
Chronic Venous Insufficiency
Deep Venous Reflux
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Chronic complication of acute DVT Multicentre study 1 yr cumulative incidence 25%, severe PTS 7%1 yr cumulative incidence 25%, severe PTS 7% Obesity increased risk (RR 1.5) Proximal DVT increased incidence (RR 1.3) Women more common (RR 1.5) Less common over 60yrs of age Reference: Risk factors for post-thrombotic syndrome in patients with a first deep venous
thrombosis. Journal of Thrombosis and HaemostasisVolume 6, Issue 12, Date: December 2008, Pages: 2075-2081L. W. TICK, M. H. H. KRAMER, F. R. ROSENDAAL, W. R. FABER, C. J. M. DOGGEN
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180 patients Class 2 graduated compression hose 1-2 years post DVT Significant reduction of PTS risk of up to 50%
Recommendation: Recommendation: Prescribe compression therapy for DVT.
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Level 1 evidence that wearing Level 1 evidence that wearing class 2 or 3 compression hose for 2 years class 2 or 3 compression hose for 2 years will reduce the incidence of PTS by 50%,will reduce the incidence of PTS by 50%,
and reduces the severity of PTS. and reduces the severity of PTS.
Bernardi E and Prandoni P. The post-thrombotic syndrome. Current Opinions in Pulmonary Medicine 2000;volume 6:pages 335-42. P. Prandoni, A.W.A. Lensing, M.H. Prins, M. Frulla, A. Marchiori, E. Bernardi, D. Tormene, L. Mosena, A. Pagnan, and A. Girolami. Below-Knee Elastic Compression Stockings To
Prevent the Post-Thrombotic Syndrome. A Randomized, Controlled Trial. Annals of Internal Medicine. 2004; 141: 249-256). Sanjeev Chunilal, Hematology, North Shore Hospital, Auckland www.vascular.co.nz http://www.podiatrytoday.com/article/3335 http://www.venous-info.com/handbook/hbk01c.html Non-pharmaceutical measures for prevention of post-thrombotic syndrome; Kolbach DN, Sandbrink MWC, Hamulyak K, Neumann HAM, Prins MH http://www.inate.org/en/1/2/6/23/default.aspx Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003; 349: 1227–1235 Alexander, Leos & Katz, Am Surg, 2002 68(12) Beasley R, Raymond N, Hill S, Nowitz M, Hughes R. eThrombosis: the 21st century variant of venous thromboembolism associated with immobility. Eur Respir J. 2003;21:374–6.
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Compression hose should be worn lifelong.Compression hose should be worn lifelong.
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[email protected]@clear.net.nz
67 Maunu Rd, Whangarei67 Maunu Rd, Whangarei
0800 1 4 VEINS0800 1 4 VEINSWhangarei, Hibiscus Coast, QueenstownWhangarei, Hibiscus Coast, Queenstown
www.skinandvein.co.nzwww.skinandvein.co.nz